Name: ______________________ Name: ______________________ Name: ______________________
Section: ____________________ Section: ____________________ Section: ____________________
1. Do you experience bullying? 1. Do you experience bullying? 1. Do you experience bullying?
o YES o YES o YES
o NO o NO o NO
2. What type of bullying did you 2. What type of bullying did you 2. What type of bullying did you
experience? experience? experience?
o Verbal bullying o Verbal bullying o Verbal bullying
o Physical bullying o Physical bullying o Physical bullying
o Cyber bullying o Cyber bullying o Cyber bullying
Please specify others: Please specify others: Please specify others:
______________________ ______________________ ______________________
3. How does it affect you? 3. How does it affect you? 3. How does it affect you?
o Academically o Academically o Academically
o Emotionally o Emotionally o Emotionally
o Physically o Physically o Physically
Please specify others: Please specify others: Please specify others:
______________________ ______________________ ______________________
4. How often do you get bullied? 4. How often do you get bullied? 4. How often do you get bullied?
o Everyday o Everyday o Everyday
o Once a week o Once a week o Once a week
o Every month o Every month o Every month
o Once a year o Once a year o Once a year
Please specify others: Please specify others: Please specify others:
______________________ ______________________ ______________________
5. What consequence would you 5. What consequence would you 5. What consequence would you
like to give to the bullies? like to give to the bullies? like to give to the bullies?
o Suspension from o Suspension from o Suspension from
classes classes classes
o Submit to guidance o Submit to guidance o Submit to guidance
o Transfer to other o Transfer to other o Transfer to other
school school school
o Pay fine o Pay fine o Pay fine
Please specify others: Please specify others: Please specify others:
______________________ ______________________ ______________________